Attachment A

Report Of Noncompliant Conduct
Information Sheet

Date: Time (if applicable):

Reporter’s name (optional and confidential):

If anonymous, tracking number:

Reporter’s department (optional and confidential):

Reporter’s phone number (optional and confidential):

Report received and recorded by:

Method of contact:

q  Telephone, Research Compliance Hotline / q  E-mail
q  Telephone, other / q  Other
q  In person

Information to obtain from reporter:

a.  Name(s) and department of individuals involved in alleged noncompliance:

b.  Description of suspected noncompliance, including date(s) and location(s), as applicable:

c.  Name(s) of any other persons who may have knowledge regarding this matter (to remain confidential for purposes of investigating the alleged misconduct):

d. Has the suspected noncompliant conduct been reported to anyone else? / q  Yes / q  No

e.  If Yes, obtain the following information:

1.  Name of person(s) reported to:

2.  Date the report was made:

3.  Was the report written or oral?

f. Can the reporter provide any documentation to assist in an investigation? / q  Yes / q  No
g. Is the reporter willing to meet with the Research Compliance Officer and/or the chair of the associated regulatory committee? / q  Yes / q  No

The following is to be completed by the Associate Vice Provost for Research and Compliance.

This report has been received by and/or forwarded to the following (check all that apply) for investigation and follow-up:

q  Associate Vice Provost for Research and Compliance
q  Research Compliance Committee
q  Institutional Review Board
q  Institutional Animal Care and Use Committee
q  Institutional Biosafety Committee
q  Radiation Safety Committee / q  Campus Safety Committee
q  Grants Administration
q  Controller’s Office
q  General Counsel’s Office
q  Internal Audit Department

The Associate Vice Provost for Research and Compliance shall attach information related to investigation, follow-up, and any disciplinary action taken.

Date investigation and file closed: